Guide to Epidural Anesthesia: For Labor and in Surgery

Introduction

Epidural anesthesia, best known for its role in alleviating labor pains, provides surgical and post-surgical pain relief for other procedures as well.

Epidurals are sometimes used in hip and knee surgery and to control pain after abdominal procedures. Most commonly though, epidural anesthesia is used during labor, at the request of the patient, to ease labor and delivery.


Model showing spine and how the needle enters the epidural and spinal space.
Model showing spine and how the needle enters the epidural and spinal space.

Epidural Explanation

What is an Epidural? How Does Epidural Anesthesia Work?

The word epidural means "over or around the dura". The dura is the tough fibrous lining that surrounds the spinal cord and spinal fluid. The epidural space is the space outside or around the dura then.

The epidural space contains blood vessels such as the epidural veins, fat and spinal nerve roots. Outside of the epidural space sit the ligaments and finally the bones of your spinal column.

Epidural anesthesia takes advantage of the fact that there are nerve roots in the epidural space. A special needle is used to locate the epidural space and a small catheter (like IV tubing but thinner) is left in the space and the needle is removed. Medicine can be infused into this tubing to keep the nerve roots numb for surgery, labor or pain relief after a procedure.

How is an Epidural Placed?

Anesthesiologists and nurse anesthetists are the only clinicians placing epidural anesthesia. Epidural injections for back pain are done by pain specialists (anesthesiologists who specialize in pain management) and sometimes by specially trained radiologists and spine specialists.

Position: For placement of an epidural, you will either sit or lay on your side. Either way, it will be important that you curl up and don't arch your back. You want to push the low part of your back toward the anesthesiologist, like a "mad cat" or a shrimp, in a "C" shape. This is important to the success of the block since you must open up the spaces between the bones for access to the epidural space.

Procedure: The anesthesia provider will clean your back of with sterilizing solution. Then, they will tell you that you will feel a pinch. This is numbing medicine injected to numb the skin and structures under the skin to make the rest of the procedure more comfortable for you.

You then will be told to hold still. You should breathe evenly, even through contractions if you are getting a labor epidural. The anesthesiologist is using a special hollow needle to find the epidural space. This should feel like they are pushing on your back with a pencil eraser or their finger. 

This part can go slow because it's not always easy to find the epidural space. If you move or have contractions, your anesthesiologist may wait for you to be still or the contraction to pass. When the anesthesia provider feels the needle pass into the ligament, they attach a syringe of saline to the end of the hollow needle. The needle is advanced very, very slowly. When the needle is still in the ligament and pressure is applied to the syringe with saline, resistance is felt. When the needle exits the ligament and enters the epidural space, there is a "loss of resistance" and resistance to pushing on the syringe suddenly "gives", and the saline is injected into the epidural space.

The syringe is removed from the needle. A small catheter is placed through the hollow needle and into the epidural space. The needle can be removed over the catheter which is left in place. So, at the end, the needle is out and the catheter is in.

Medicine is now injected into the catheter and pain relief is on the way!

Complications of Epidural Anesthesia

Every medical procedure has potential side effects and complications.

Failure: The biggest risk of the epidural is failure. The epidural can fail completely or partially. More commonly, the epidural anesthesia works, but perhaps only on one side or in a patchy distribution. Sometimes this has to do with the path the catheter takes in the epidural space and can sometimes be improved if the anesthesiologist pulls the catheter back a bit. Sometimes, there are barriers like strands of connective tissue or scar in the epidural space that keeps the epidural medicine from spreading and numbing all of the nerve roots. There is no way to predict who will have complete anesthesia and who will have patchy anesthesia. If the epidural anesthetic doesn't spread well to give good pain relief, this is disappointing for the patient and the doctor.

Bleeding: Because there are blood vessels in the epidural space, bleeding is a risk. Usually, if one of these blood vessels bleeds, it clots off easily and doesn't cause a problem. However, if you are on blood-thinners, or rarely as a random event, the blood vessel doesn't clot off. This becomes a medical emergency because if the bleeding isn't stopped, a hematoma (collection of blood) can form in the epidural space. The hematoma compresses the spinal cord and permanent paralysis can result if the hematoma isn't diagnosed (usually with MRI) and surgically relieved within a few hours. Pregnant women have bigger and more blood vessels in the epidural space, so if you are pregnant and on blood thinners, you will most likely not be able to have an epidural for labor.

Luckily, this complication is extremely rare, with an incidence of only about 1 in 150,000 to 190,000 epidural anesthetics, as reported in a review of the literature published in the journal "Anesthesia and Analgesia" in 2002. That was seven hematomas in 1.3 million epidurals.

Infection: Anytime a needle or medical instrument passes from the outside environment, through the skin to an internal space like the epidural space, infection is a risk. People who are taking drugs (like chemotherapy or drugs for autoimmune diseases) that suppress their immune systems are at increased risk. The incidence for this epidural complication is about 1 in 2000. Treatment is with antibiotics and possibly surgical drainage.

Nerve Damage: The incidence of nerve damage attributable to epidural analgesia and anesthesia is harder to compute. Labor epidurals usually are only in place for a few hours and then are removed. While it's possible that the catheter or medicine can irritate the nerve roots and cause lasting numbness or weakness, it doesn't seem to be very common.

If you have a lumbar epidural for labor and have numbness or weakness afterwards, it's possible that the nerve problem is from labor itself. The delivery position used in the United States of putting the legs in stirrups and then flexing from the hips, can damage several nerves. This is actually quite common. Most often, numbness over the front of the thigh and "foot drop" are from this positioning. Also, pressure from the baby's head on the pelvic brim causes certain kinds of nerve injury.

Regardless of cause, these nerve deficits are usually temporary and resolve on their own or with physical therapy in more significant cases. There are muscle and nerve tests that can be done to help figure out the origin of the nerve injury if that becomes important.

Epidural Anesthesia

Have you ever had an epidural?

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How was your experience with epidural anesthesia? 11 comments

J Sunhawk profile image

J Sunhawk 5 years ago from South Carolina

I know nothing about epidural anesthesia, but your hub is well laid out to provide info for people who need it.


TahoeDoc profile image

TahoeDoc 5 years ago from Lake Tahoe, California Author

Thank you J. Sunhawk. I feel that everyone should have as much information as possibe to be active participants in their own medical care. Unfortunately, our system is not set up for doctors and patients to spend a lot of time together and even when lengthy explanations are given and received, the info doesn't always "stick" or make sense.

There is also a lot of misinformation out there, especially where labor epidurals are concerned. I hope to provide clear and balanced information that people can use. I have been a patient as well as a doctor and hope to help so I have a somewhat unique perspective.


kiani thomason 5 years ago

im 19 and this is my first child and i want an epidural, but the needle looks like it causes a lot of pain. the needle is very long but the whole needle doesn't go inside of your back does it? could someone answer me please so that i could try to get over my fear. i do not think that im ready to go natrual for my first child.


TahoeDoc profile image

TahoeDoc 5 years ago from Lake Tahoe, California Author

Hi Kiani- It's certainly normal to be nervous about many aspects of your first birth and the epidural is no exception.

When we do the epidural, we use numbing medication, given through a very small needle first to numb the skin and the tissue under the skin. After this, most people feel pressure-- like a pencil eraser being pushed on your back.

The epidural needle is the size and shape that it is, because of the anatomy of the spinal column. The epidural space is under the layer of skin, fat, between the spinal bones, and past some pretty tough ligaments. It has to be long enough to reach through that. It also has to be just big enough to be hollow so that we can put the very skinny epidural catheter (tube) through it. The catheter stays in and the needle comes out.

How much of the needle goes into your back quite honestly depends on how much excess fat you have in your back and how deep your spinal column is. Usually, insertion of somewhere between three and six centimeters is sufficient.

Of course, there are risks as discussed above, but they really are pretty rare considering how many of these are done per day.

I have had two of these myself after having placed thousands in other people. If I thought they were painful, I wouldn't have done it. They really were not. Some people can feel more pressure than others and occasionally, you can get an electric-like feeling as the needle touches near a nerve. It may be more painful if you are unable to hold still, if you have anatomic challenges to finding the right space or whatever. I've had one patient get a spinal headache in over 10 years of doing these and she wished she hadn't gotten the epidural. I've never had one patient tell me that they regretted the epidural because getting it was too painful to get. Not once.

Please, please tell your anesthesiologist or nurse anesthetist what you are most afraid of before they start so they can address your specific concerns. The OB nurses will be a great resource, as well.


TahoeDoc profile image

TahoeDoc 5 years ago from Lake Tahoe, California Author

Oh, and having said all that, the decision to get an epidural or not is yours to make. I don't 'sell' them. I usually tell people to keep their options open if they think they might want one. Get into the labor, see how you do and decide. But, it's good to have done some research before hand because it's tough to make an informed decision when you are 6cm in a lot of pain-- it's a little one-sided at that point, lol.


Sebbie 4 years ago

I am due to have a hysterectomy soon and would love to avoid a general anesthetic if possible . Is it possible to have an abdominal hysterectomy with an epidural .


TahoeDoc profile image

TahoeDoc 4 years ago from Lake Tahoe, California Author

Hmmm....If it is an open procedure or purely a vaginal hysterectomy, it could be done. However, most are done today using laparoscopy. If the laparoscopic technique is used, general anesthesia is quite likely the only option. I explain to my patients that it IS the only option due to problems with pain and breathing that cannot be covered by epidural or spinal anesthesia (because they inflate the abdomen with gas). To me, it is too risky to do otherwise.

Laparoscopic (scope surgery) techniques allow for a MUCH, MUCH smaller incision with less postop pain. Less postop pain cuts down on the risk of breathing difficulties and changes in blood pressure and heart rate. The amount of risk and post-op complications saved by the laparoscopic technique probably outweigh any danger of the general anesthetic.

If you have significant medical problems that make anesthesia risky, discuss this more with your doctor. If you have more questions about anesthesia, please let me know- I also have articles on general anesthesia if they could be helpful to you.

Good luck!


Josie 4 years ago

I am 325 lbs and due to have a baby soon. I have not had an epidural with previous births, and I'm exploring my options right now. What can I do to ensure a successful epidural during labor?


TahoeDoc profile image

TahoeDoc 4 years ago from Lake Tahoe, California Author

Hi Josie - First, congrats on your impending arrival!! If you decide that you want an epidural, I think the most important thing you can do is be educated about what will be expected--and what you can expect, beforehand. I hope my 'hubs' help you with that.

So, when they come to place the epidural, they will ask you to either lay on your side or sit up. Either way, the most important and hardest thing is to get into --and hold-- the position they want you in. This is usually described as making a C with your back, curling up like a cat with your low back pushed OUT, not arched in, toward the anesthesiologist. You will feel like there is no way you can do this, but you can. Even with rip-roaring contractions, women almost always feel better once they get in this position for a few minutes. And they hold still better than they think they will.

I'm guessing you mentioned your weight because you are aware that this can make an epidural harder. And, you are correct. It isn't impossible and sometimes it doesn't seem to be much of a problem at all. But, sometimes, it can be a challenge. The anesthesiologist uses bony landmarks to find the right spot for the epidural. If he/she can't feel the top of the hips or the backbones, it could present more of a challenge. For your part, be as patient as you can. It can take longer if they are finding the space more slowly. Slow, even breaths (no sudden, really deep breaths), relaxed shoulders and arms and following instructions will help the most.

Let me know how you do.

Good luck and again, congrats! I do find that a lot of times, subsequent pregnancies can be easier and often, women won't even request epidurals if they have given birth before. Everyone - and every pregnancy is different, though, so do what you need to do to have a safe and happy experience that's right for you!!


karen 4 years ago

hi im going on my second baby for the first baby i had the epidural i am considering for this baby also but with my first it was so strong i couldn't feel at all my pushing is there anything a little less strong?


TahoeDoc profile image

TahoeDoc 4 years ago from Lake Tahoe, California Author

Hi Karen- The rate at which the epidural delivers medicine can be adjusted. If it was too strong, tell your anesthesiologist and they should be able to run it at a slower rate.

Most places now are already using more dilute numbing medicine, so if you tell the anesthesia doc, they should be able to adjust it for you. Also, if you get the epidural and are getting so numb that you can't move your legs, tell the nurse that it's too strong at that point so they can either turn it off for a while or turn it down. Some people are just more sensitive to the medications.

Of course, if your hospital uses an entirely different protocol, then this all may not be possible. Just make sure you tell the anesthesiologist before they start the epidural what your concerns and wishes are.

Good luck & Congrats in advance :)

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